โรคหลอดเลือดสมอง Cerebrovascular disease (CVD) CVA Stroke

งานนำเสนอเรื่อง: "โรคหลอดเลือดสมอง Cerebrovascular disease (CVD) CVA Stroke"— ใบสำเนางานนำเสนอ:

1 Acute Ischemic Stroke & Transient Ischemic Attack (TIA) Sumet Preechawuttidej, M.D.

2 โรคหลอดเลือดสมอง Cerebrovascular disease (CVD) CVA Stroke
“Rapidly developed clinical signs of focal (global) disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than a vascular origin.”

3 ผลของโรคหลอดเลือดสมอง
เสียชีวิต Stroke ความผิดปกติ muscle weakness, ataxia, loss of sensation, etc ปัจจัยเสี่ยง ความพิการ Inability to walk, feed, etc เกิดโรคซ้ำ (สมองเสื่อม vascular dementia)

4 อายุคาดเฉลี่ยคนไทย พ.ศ. 2546-2556

5 รายงานการสำรวจพฤติกรรมเสี่ยงโรคไม่ติดต่อและการบาดเจ็บ

6 โรคที่เป็นสาเหตุของความสูญเสียปีสุขภาวะประชากรไทย
อัตราตายของประชากรไทย

7 Content Acute Ischemic Stroke & TIA Etiology Clinical manifestation
Diagnosis Management Prevention

8 Approach to Cerebrovascular disease
Definition conditions in which injury to the brain or spinal cord occurred from a vascular cause 2 main types: ischemic and hemorrhagic stroke

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10 The perforators Charcot-Bouchard aneurysm Parent artery

11 Acute Ischemic Stroke & TIA

12 Etiology Ischemic Stroke Subtypes (TOAST classification)
Large-artery atherosclerosis Cardioembolism Small-vessel occlusion (Lacunar infarction) Stroke of other determined etiology Hypercoagulable disorder Venous sinus thrombosis Vasculitis Stroke of undetermined etiology

13 เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity
Risk Factors เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity เปลี่ยนแปลงได้ Modifiable Behaviors Cigarette smoking Alcohol abuse Physical inactivity Medical Conditions Hypertension Cardiac disease Atrial fibrillation Dyslipidemia Diabetes mellitus Carotid stenosis Prior TIA or stroke Elevated homocysteine Atherosclerosis of aorta Sacco RL, et al. Stroke 1997;28: Pancioli AM, et al. JAMA 1998;279:

14 Prevalence of Stroke by Age and Sex NHANES III: 1988-94
Risk Factors CDC/NCHS.

15 เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity
Risk Factors เปลี่ยนแปลงไม่ได้ Non-modifiable Age, Gender, Race, Heredity เปลี่ยนแปลงได้ Modifiable Behaviors Cigarette smoking Alcohol abuse Physical inactivity Medical Conditions Hypertension Cardiac disease Atrial fibrillation Dyslipidemia Diabetes mellitus Carotid stenosis Prior TIA or stroke Elevated homocysteine Atherosclerosis of aorta Sacco RL, et al. Stroke 1997;28: Pancioli AM, et al. JAMA 1998;279:

16 Risk Factors

17 อาการของโรคหลอดเลือดสมอง
Clinical manifestation อาการของโรคหลอดเลือดสมอง รวดเร็วหรือทันทีทันใด!! อ่อนแรงของร่างกายครึ่งซีก ชาครึ่งซีก เวียนศีรษะ ร่วมกับเดินเซ ตามัว หรือ มองเห็นภาพซ้อน พูดไม่ชัด ลิ้นแข็ง ปวดศีรษะ อาเจียน ซึม ไม่รู้สึกตัว

18 Transient ischemic attacks (TIA)
Duration is <24 hours, but most TIAs last <1-2 hours The risk of stroke after a TIA is ~10–15% in the first 3 months Most events occurring in the first 7 days ABCD2 score

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20 MANAGEMENT

21 History and Physical examination
Determining the exact time when symptoms began or the last time the patient was known to be well Concomitant medical illnesses Risk factors

22 History and Physical examination (cont.)
Vital signs Cardiovascular systems General neurologic examination The National Institutes of Health Stroke Scale (NIHSS)

23 NIHSS 1. Level of consciousness Level of consciousness Question
Command 2. Best gaze 3. Visual field 4. Facial palsy 5. Motor arm 6. Motor leg 7. Limb ataxia 8. Sensory 9. Best language 10. Dysarthria 11. Extinction and Inattention

24 SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT SUSPICIOUS STROKE
<4.5 hr hr Stroke fast track Emergency lab + CT brain NC Emergency lab + CT brain NC STROKE STROKE General Mx Hemorrhagic Ischemic Candidate for thrombolytic therapy? Consult neuroSx

25 Initial investigation and Workup
Blood test FBS, CBC, Lipid profile, BUN/Cr, Electrolyte, PT, PTT, INR, UA Cardiac workup EKG 12 lead, CXR If suspect cardioembolism  TEE, Holter monitoring Pt. age <45 yr without evidence of cardioembolism/ atherosclerosis risk factor ESR, ANA, Anti HIV, VDRL, LFT, Thrombophilia lab Vascular workup Carotid duplex US, TCDUS MRA, CTA

26 Brain imaging CT brain non contrast DDx Ischemic or Hemorrhagic
MRI brain (further investigation) Early signs in CT (MCA infarction) Loss of gray-white junction Insular ribbon sign Blurring of borders of basal ganglia Dense artery sign

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28 Treatment IV thrombolytic treatment General management
Antithrombotic treatment Stroke Unit and Rehabilitation

29 IV thrombolytic therapy
Indication Clinical diagnosis of stroke Onset ≤ 4.5 hr Age > 18 yr CT brain  no hemorrhagic or edema of >1/3 of the MCA territory Consent by patient or surrogate

30 IV thrombolytic therapy (cont.)
Contraindication (onset within 3 hour) Sustained BP ≥185/110 mmHg despite Tx Platelet < 100,000; Hct < 25%; Glucose < 50mg% or > 400 mg% Use heparin within 48 hr and prolonged PTT or elevated INR Rapidly improving symptom  NIHSS ≤ 4 Prior stroke or head injury within 3 months; prior intracranial hemorrhage Major surgery in preceding 14 days Minor stroke symptom Gastrointestinal bleeding in preceding 21 days Recent myocardial infarction Coma or stupor

31 IV thrombolytic therapy (cont.)
Additional contraindication in patient (onset within 3 – 4.5 hour) History of warfarin use Age > 80 year Diabetic with prior ischemic stroke NIHSS > 25

32 IV thrombolytic therapy (cont.)
Administration of rt-PA (Recombinant tissue-plasminogen activator) 0.9 mg/kg (maximum 90 mg) IV as 10% of total dose by bolus The followed by remainder 90% over 1 hour No other antithrombotic treatments for 24 hours For decline in neurologic status/uncontrolled BP  stop infusion and give cryoprecipitate and reimage brain immediately Avoid urethral catheterization

33 General management Keep SpO2 > 94% Antihypertensive drug
SBP ≤220 mmHg or DBP ≤120 mmHg with CHF, Aortic dissection, Acute MI, Acute renal failure, Hypertensive encephalopathy If SBP >220 mmHg or DBP >120 mmHg Decrease blood pressure 10-15% Nicardipine 5 mg/hr IV Keep BP <180/105 mmHg in Pt. received thrombolysis

34 General management (cont.)
IV hydration Isotonic solution (0.9%NaCl) NPO when Unconsciousness Suspected large infarction Tendency to surgery Infratentorial infarction

35 General management (cont.)
Blood glucose controlled Keep mg% Avoid high body temperature If patient seizure  Antiepileptic drug (no need prophylaxis) Tx co-morbidity; MI, electrolyte imbalance Early mobilization for prevention DVT Swallowing evaluation

36 Medical treatment Antiplatelets
Aspirin 160 – 325 mg/day in first 24 – 48 hour No Aspirin within 24 hours after thrombolytic therapy Anticoagulants Others; Immunosuppressive drug in vasculitis

37 Tx Increase intracranial pressure
Intubation if deteriorated consciousness Semifowler position (20 – 30 degrees) Hyperventilation  16-20/min keep pCO mmHg Osmotherapy 20% Mannitol 1g/kg IV in min then g/kg IV in 10 min q 4-6 hour (max 2g/kg/day) for 24 – 48 hours Keep Serum Osmo <320 mmol/L Consult neurosurgeon for decompressive craniectomy

38 Stroke Unit Rehabilitation Swallowing evaluation

39 Stroke Unit (cont.)

40 Stroke Unit (cont.)

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42 Rehabilitation Contraindication
Body temperature >38 degrees celcius HR >100 or <60/min BP >180/110 or <90/60mmHg Cardiac condition: MI, arrhythmia Dyspnea Deteriorated consciousness Seizure

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44 Secondary prevention Atherosclerosis risk factor BMI <23 kg/m2 DM
HbA1C < 7% HT <140/90 mmHg in general patient <130/80 mmHg in DM patient Smoking  stop Abnormal blood cholesterol (low HDL, high LDL) Keep LDL < 100 mg/dL in general patient Keep LDL < 70 mg/dL in DM/heart disease patient Keep TG < 150 mg/dL, HDL >40 mg/dL (male), >50 mg/dL (female)

45 Secondary prevention (cont.)
Antiplatelet agent Non-cardioembolic stroke ASA mg/day Clopidogrel 75 mg/day ASA + dipyridamole 50/400 mg/day Cilostazol 200 mg/day

46 Secondary prevention (cont.)
Anticoagulant Cardioembolic stroke Warfarin  keep INR in patient with Persistent or paroxysmal AF Acute MI and LV thrombus Mechanical heart valve

47 Thank You For Your Attention